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Are you up to standard? Why you must have a successor custodian

Are You Up to Standard?, June Messenger 2019, Latest News Archive, Messenger, Professionalism & Standards | Posted June 13, 2019
Recently, an Alberta physician passed away after a lengthy illness. While the physician was already out of practice and their passing was not unexpected, there was no successor custodian in place. The physician inadvertently left their spouse, who was not authorized to act as a custodian under the Health Information Regulation, to assume the duties of the successor custodian.

As outlined in the Patient Record Retention standard of practice, if you are the custodian of patient records, you must have a successor custodian under the Health Information Act (section 35(1)(q)).

  • All physicians are custodians unless explicitly identified otherwise.
    Unless you provide services under contract, or are employed by a custodian and your practice arrangement identifies you as an affiliate, you have ongoing custodial responsibilities for the patient records to which you contribute.
  • All physicians who are custodians must have a successor.
    To ensure continuity of care and ongoing access to health information, custodians must have arrangements in place to deal with contingencies (e.g., you become ill, pass away or move to a geographically-distant location).
  • Not just anyone can be a successor custodian.
    Per the Health Information Regulation (section 2(2)), only regulated healthcare professionals are considered custodians. This means you cannot rely on your spouse, your neighbour or your office manager to be your successor. Additionally, your successor needs to be close enough to your practice location to ensure your patients have reasonable access to their records.

You can also use an eligible entity (as designated in section 2(1)) of the Health Information Regulation) or a records management company to fulfill this role.

A physician who fails to designate a successor custodian not only contravenes CPSA’s Standards of Practice, but also puts their patients’ safety at risk. Please ensure you have a successor custodian today.

For more information on physicians as custodians and successor custodians, please refer to the Advice to the Profession document.

Questions? Contact Chantelle Dick, Standards of Practice Coordinator, at for more information or template successor custodian agreements.

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